Medicaid expansion increases CRC screening in Kentucky

A research team evaluating the impact of Medicaid expansion on the rates of colorectal cancer (CRC) screening, incidence, and survival in Kentucky’s low-income population, have found that the number of Medicaid patients who received screening after the expansion was more than triple the number of patients who were screened before the expansion. Additionally, CRC patients relying on Medicaid exhibited improved survival after the expansion compared to before it was implemented. The study. ‘Impact of the Affordable Care Act on Colorectal Cancer Screening, Incidence, and Survival in Kentucky’, was published in the Journal of the American College of Surgeons.

The Affordable Care Act's Medicaid expansion provided insurance coverage to those at 138 percent of the federal poverty level. In Kentucky, the expansion meant that an additional 634,807 low-income people gained access to Medicaid. Many people in this population have a low level of education and don't have easy access to a physician, especially the more rural Appalachian population in eastern Kentucky.

"For me, it was bit of a wake-up call living in our society and seeing the population that I treat in Kentucky, particularly in Appalachia," said lead study author, Dr Avinash Bhakta, a colorectal surgeon at the University of Kentucky Markey Cancer Center, Lexington. "Many of these patients paved their own roads to come see me in Lexington. We didn't really see much study on the effect of the Affordable Care Act Medicaid expansion, and with our population having the leading incidence and mortality rate of CRC in the country, we felt that it was an ideal population to study this potential impact."

Bhakta said he began treating more and more patients from Appalachian Kentucky, and he wanted to look further into how the Affordable Care Act could be related to the increase of patients he was treating.

To conduct the study, the researchers obtained data on Kentucky's CRC screening, incidence, and outcomes from the Kentucky Hospital Discharge Database and the Kentucky Cancer Registry. The study population included 930,176 patients older than 20 years who underwent CRC screening from January 2011 to December 2016.

A total of 408,500 patients were screened before Medicaid expansion (January 2011 to December 2013) and 521,676 patients were screened after Medicaid expansion (January 2014 to December 2016). The researchers obtained measures including demographics, insurance coverage based on information at the time of diagnosis, socioeconomics (percentage below poverty status and high school education at the county level), and clinical information (tumour grade, stage at diagnosis, and survival).

One of the most significant results from this study, Dr Bhakta said, was that patients with Medicaid demonstrated the highest increase in CRC screening. A total of 69,328 Medicaid patients received screening after the expansion compared with 20,980 patients who were screened before the expansion, an increase of 230 percent. Additionally, 43.7 percent more Appalachian patients received screening after the expansion. When looking specifically at Medicaid patients, the researchers wrote, individuals in the 51-65 age group had the highest improvement in screening with an increase of 292.5 percent. Medicaid coverage of Appalachian patients increased by 199 percent.

From January 2011 to December 2016, 11,441 Kentucky patients were diagnosed with CRC. When separated by insurance, the proportion of Medicaid patients diagnosed with CRC increased by 132.4 percent after Medicaid expansion, the authors wrote. Dr Bhakta said that increase was "a difficult number for me to swallow," because with increased screening, there should be a decline incidence. However, Dr Bhakta noted that this research is still young. If the researchers follow the data for another five or ten years, he anticipates seeing a decline incidence.

The researchers also reported that after expansion, Medicaid patients exhibited improved survival compared with patients prior to expansion. The survival differences after expansion were evident in Medicaid patients after the first year and increased each year thereafter. Appalachian patients with Medicaid coverage had significantly improved survival after expansion compared with before expansion, the researchers wrote.

"We saw that month to month post expansion, there was an improvement in survival from the pre-expansion era in our Medicaid population," added Dr Bhakta. "We were able to follow many of these patients for up to eight years, and we are continuing to keep track of them and their recurrences and overall survival."

The most important takeaway from this study, Dr Bhakta said, is that as more people get screened for CRC, more people will have improved survival.

"We know that with increased screening, we're able to get increased detection of earlier polyps," he said. "The Medicaid expansion allowed us to get access to a lot of near-poor patients that would have otherwise not been able to get screened."

Now that the researchers have identified the problem, they will continue to gather data and find solutions for the state's high mortality rate from CRC.

"After these individuals are screened and diagnosed with colorectal cancer, are we not navigating them appropriately to surgery? After their operations, are the patients with advanced tumours not getting chemotherapy in a timely fashion?" asked Dr Bhakta. "Finally, is this patient population that we treat at UK Markey Cancer Center resistant to traditional chemotherapeutic agents? These questions and barriers are important for us to investigate in order to continue our fight against colorectal cancer.”

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